12080069 CITY OF CUPERTINO BUILDING PERMIT
B1111.UING ADDKF.SS: 10049 DOVE OAK CT CUNI'RAC'I'OR:Pli'1'13RSEN-DEAN INC PERMITNO: 12080069
O\VNER'SNAME: WAGENERSHIRLEYJ 7980 E.NI'F.RPRISE DR DATE ISSUED:08/072012
O\\'NER'S PHONE: 6509409220 NEVA R K,CA 94560 PHONF,NO:(51OH94-9982
❑ LICENSED CONIRACI'OR'S DIiCLARATION 13UI LDING PERMIT INFO: 13LDG r ELECT I- PLUMB r
License Class Lie.N
NI IiCFI [ RESIDENTIAL COMMERCIAL
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE SHAKE ROOF INSATALL PRESIDENTIAL TL
(commencing with Section 7000)of Division 3 of the Business S Professions SIIINGLES OVER 30.4 FELT AND CDX SHEATHING-I ISQFf
Code and that inv license is in full force and effect.
hereby affirn under penalty osc
f perjury one of the folluing loo declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
pert'orhance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq,Ft Floor Area:0 Valuation:$6000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
,\I'N Number:34232097.00 Occupancy'I'ypc:
APPLICANT CERTIFICATION
I cenify that I have read this application mid state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnilvandkeepharmlesstheCityofCupertinoagainstliabilities.judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may acerae against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands mid will comply
with all non-point source regulations per the Cupertino Municipal Cade,Section
9.18. Issued by: Date:
Signature Date
❑ O\YNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material beinginstalled.If a roof is
I hereby affirm that Iran exempt from the Contractor's Licensc Law Formic of installed without first obtaining an inspection,I agree to remove all new materials for
the fullooing too reasons: inspection..
L as owner of the property,or my employees with wages as their sole compalsation,
will do the work,tad the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business K Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business fi Professions Code). ALL 1300E COVIiRINGS TO BE CLASS"A"OR BE I-I ER
I hereby affirm under penalty of perjury one of the following three
declarations: IIA7.ARDOIIS MATFRIAI S DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's 1 have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Ileallh S Safety Code.Sections 25505.25533,and 25534. 1 will maintain
performance of the work far which this permit is issued. compliance with the Cupertino Municipal Code.Chapter 9.12 and the I leallh S
1 have and will maintain Worker's Compensation Insurance,as provided for by Safely Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for tie perfomhance of the work for which Ihfs Additionally,should 1 use equipment or devices which emit hwardous air
contaminants as defined by the Bay Arca Air Quality Management District t will
permit is issued. maintain compliance with the Cupertino Dl unicipal Code.Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall I Icalth&Safely Code.Sections 25505.25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,a0er making this certificate of exemption.1 0,%ner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANTCERT'I FIC TION I hereby amrtn tum there is a constniction lending agency for.the performance of work's
I certify that I have read this application mid state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances mid state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indenmlt'v and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used ars public records.
9.18.
Licensed Professional
Signature Date